May 12 2010

I Don’t Feel Your Pain

A recent study uses EEG to look at brain activity in doctors and control subjects while viewing another person being poked with either a needle or a cotton swab. The control subjects showed activity in parts of the brain consistent with empathy – a negative experience in reaction to the pain of  the other. The doctors, however, did not demonstrate this brain activity.

These results, while preliminary, are not surprising to me at all. You may find it odd that a doctor, who is supposed to be especially attentive to the comfort of their patients, would be inured to their pain. But this makes perfect sense.

Let me start by recounting my own personal experience as a representative anecdote. The first invasive procedure most medical students learn is blood drawing, which involves sticking a needle into the vein of a patient in order to fill tubes with blood to send off to the lab.

This is no big deal, but when I first learned to do this I felt a strong inhibition against the deliberate infliction of pain on another person. Obviously the purpose of the procedure was diagnostic, the patient consented to the procedure because they knew it was medically necessary. But there was simply a negative emotional reaction to the pain I was inflicting, as minor as it was.

This was a problem. Optimal blood drawing technique, to minimize patient discomfort, requires no “flinching” or hesitation on the part of the blood drawer – one quick smooth motion is ideal. I found I had to consciously suppress the instinctive inhibition, which took a little practice. After a few weeks of regular blood drawing, however, I found that I could focus on the procedure and was no longer distracted by any pesky empathy.

This experience prepared me for the more elaborate and uncomfortable procedures I would learn as my training progressed.

This desensitization is both unavoidable and necessary. I also found that it is part of a broader principle in medicine, the distinction between sympathy and empathy.

Doctors and other health care providers need to have sympathy and sensitivity toward their patients. They need to understand what their patients are going through, and make every effort to minimize emotional and physical discomfort, as well as treat their patients with dignity. This is part of being a professional.

Empathy, however, goes beyond sympathy – it involves experiencing a negative emotion in response to your patient’s pain (mental or physical). While sympathy is good, empathy is counterproductive – for both the physician and patient.

For the physician, the main problem is burn-out. If you actually experienced all the emotion you encountered on a daily basis as a physician (granted – depending on your specialty) you wouldn’t last long. A bit of professional distance is necessary for your own emotional health.

But further, empathy is not in the best interest of the patient. Getting emotionally wrapped up in a patient’s situation compromises objectivity. This can be a subtle but devastating problem. I have seen doctors over-treat pain with narcotics to the patient’s detriment, because they were emotionally bothered by the patient’s pain. Empathy can also lead to failing to consider terrible diagnoses, or ordering tests, procedures, or interventions out of desperation, even when the risks outweigh the benefits.

Patients need their physicians to be detached, objective, and professional – not emotional. This is exactly why physicians should not treat their own family members or loved-ones.

And to emphasize this point – detached does not mean uncaring. The professional relationship means that we are sympathetic, caring, and non-judgmental in a universal systematic way – regardless of our feelings for a patient or sympathy for their situation. We give the same care to patients we like as to those who are confrontational and irritating. We are detached from the positive and negative emotional reactions to patients.

To further emphasize – I think it is important for physicians to really understand what their patient’s go through. Modern medicine can be scary, embarrassing, and uncomfortable at times. When physicians experience that themselves, or through a family member, or at least really try to imagine what it would be like – they are in a better position to tend to their patient’s needs.

It can be a delicate balance, but it is an important one to strike. In general, in my experience, medical education does adequately address this issue. It can always be better, but most physicians I know are very attuned to this situation.

So, while this is a small study, the results confirm what most physicians already know. We don’t feel your pain, and you don’t want us to. But we do understand and sympathize with it.

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